Icterus neonatorum presentation for students

Introduction
Definition
Metabolism and excretion of bilirubin
Causes
Symptoms
Types
Physiological jaundice
Pathological jaundice
Breast milk jaundice
Neo natal jaundice is a yellow discoloration of the white part of the eyes and skin in a newborn baby due to high bilirubin level.
Neo natal jaundice becomes apparent at serum bilirubin concentration of 5-7mg / dL.
Shoulder and trunk 8-10mg/dl
Lower body – 10-12mg/dl.
Entire body 12-15 mg /DL

1. ICTERUS NEONATARUM Submitted to Mrs pushpa kerketta Clinical tutor College of nursing Rims Ranchi Submitted by Purnima Kumari Basic BSC Nursing 4 th year (2017-2021) Roll no – 25 College of Nursing RIMS Ranchi.

2. CONTENTS Introduction Definition Metabolism and excretion of bilirubin Causes Symptoms Types Physiological jaundice Pathological jaundice Breast milk jaundice Risk factors Laboratory evaluation Treatment
Complication Prevention Summary Evaluation Bibliography

3. Jaundice in the newborn/ neonatal jaundice Neo natal jaundice is a yellow discoloration of the white part of the eyes and skin in a newborn baby due to high bilirubin level. Neo natal jaundice becomes apparent at serum bilirubin concentration of 5-7mg / dL. Shoulder and trunk 8-10mg/dl Lower body – 10-12mg/dl. Entire body 12-15 mg /DL

4. Definition Neonatal jaundice is the yellow discoloration of skin and the mucosa is caused by accumulation of excess of bilIrubin in the tissue and plasma.

5. Metabolism and excretion of bilirubin

6. Cont.

7. Causes of neonatal jaundice Predisposing factor ABO and Rh incompatibility Maternal diabetes Race Poor breast feeding

8. SYMPTOMS /CLINICAL MANIFESTATION Yellow skin and sclera Poor feeding Brown urine Fever High pitch cry Without treatment can progress to acute bilirubin encephalopathy (kernicterus)

9. Types of neonatal jaundice Physiological jaundice/Icterus neonatorum Pathological jaundice
Breast milk jaundice

10. Physiological jaundice (Icterus neonatorum) The jaundice usually appears on 2 nd and 3 rd day and disappears by 7 th – 10 th day .

11. Characteristics The clinical pattern of physiologic jaundice in term infants including a peak indirect – reacting bilirubin level of no more than 12mg/dl on day 3 of life It’s disappers by one week in full term infants and 2 week in preterm infants Healthy baby

12. Causes Increased red cells breakdown Decreased albumin binding capacity Enzyme deficiency Increased enterohepatic capacity Infection Bruising Polycythaemia
Dehydration

13. Management of physiological jaundice Adequate feeding Careful observation of newborn will help distinguish between healthy babies with abnormal In premature babies rising bilirubin level to critical level require use of phototherapy or phenobarbitone administration.

14. Pathological jaundice Pathological jaundice usually appears within 24 hours of birth and its characterized by a rapid rise in serum bilirubin and prolonged jaundice.

15. Features of pathological jaundice Clinical jaundice appears within the first 24 hours of life. Increase in bilirubin more than 5 mg /dl per day
Total bilirubin more than 13 mg / dl. Persistence of clinical jaundice for 7 to 10 days in full term infants and 2 week in preterm infants

16. Causes of pathological jaundice Increased bilirubin production due to excessive red cell hemolysis. - hemolytic disease of the new born - deficient red cell enzyme glucose -6- phosphate dehydrogenase. Defective Conjugation Transport and excretion Failure.

17. Breast milk jaundice It is caused by prolonged increase enterohepatic circulation of bilirubin. Bilirubin peaks at 10-15 days of age The level of unconjugated bilirubin is at 10-30mg/dL. If breasts feeding is interrupted for 24 hours the bilirubin level falls quickly. Breast milk jaundice is commonest cause of prolonged jaundice in term infants. Beta glucuronidase present in the breast milk of some mother.

18. Risk factor of neonatal jaundice Birth trauma or evident bruising Prematurity Family history of jaundiced sibling aur hemolytic disease
Delayed feeding or meconium passage Jaundice within the first 24 hours suggests hemolysis

19. Laboratory evaluation Serum bilirubin Direct Coombs test Indirect coombs test
Hemoglobin estimation Reticulocyte count ABO blood group and Rh type

20. Kramer index Assessment of neonatal jaundice Grade Affected body part Bilirubin level in blood (mg/dL) 1 Face 5 2 Chest 10 3 Abdomen and thigh 12 4 Hands and legs 15 5 Palm and soles >15

21. Treatment of jaundice Phototherapy Pharmacological therapy Exchange transfusion

22. 1. Phototherapy Phototherapy can be used to prevent concentration of unconjugated bilirubin in blood from reaching level where neurotoxicity may occur. Bilirubin levels indicating phototherapy are: for term infants who become jaundiced after 48 hours: 17- 22mg/ dl. For preterm infants more than 1,500 g weight : 8-10mg/dl
For preterm babies Less than 1,500g weight : 5-8mg/dl.

23. Mechanism of phototherapy Fluorescent lamp with an output of 420 – 480nm wavelengths are the most effective. Double phototherapy- overhead light- plus light from below or fiberoptic blanket. Conjugated bilirubin absorbs light maximally at that range and undergoes photo isomerization and it’s converted to the less toxic polar isomer which is is excreted into the bile. Phototherapy also converts bilirubin to lumibilirubin by structural isomerization lumibilirubin is excreted in the bile and urine without conjugation.

24. Care of neonates undergoing phototherapy Cover the eyes and genital area Supplemental hydration , frequent breast feeding encouraged. Observe visible side effects Estimation of bilirubin levels Monitor temperature and observe skin for rash dryness . Observe neurobehavioral status . Monitor serum calcium level

25. Complication of phototherapy Watery diarrhoea Skin rashes Dehydration Bronze baby syndrome
Low calcium level Retinal damage

26. Pharmacological therapy Phenobarbital therapy – phenobarbitone induces hepatic microsomal enzyme and increase bilirubin conjugation and excretion . Loading dose of 10 mg /kg on day 1 Maintenance dose of 5-8mg/kg/day for next 4 day given . Antibiotic are administered for 3-5 days .

27. Exchange transfusion Exchange transfusion is a life saving procedure in severely affected hemolytic disease of the newborn. An exchange transfusion process removes bilirubin from the body and in cases of hemolytic disease also replaces sensitized erythrocytes with blood that is compatible with the mother and infant serum.

28. Indications of exchange transfusion When there is progressive rise of bilirubin( >1mg/dL/hour) inspite of phototherapy. Rate of bilirubin rise >0.5mg/dL/hour despite phototherapy when Hn is between 11-13g/dL. To improve anaemia in congestive cardiac failure of neonate. The serum bilirubin level of the infant is >12mg/dL in first 24 hours and >20mg/dL in neonatal period . Progressive anaemia of the neonate
When phototherapy fails to prevent the rise of Bilirubin to be in toxic levels Cord blood hemoglobin is <11g/dL and bilirubin level is >5 mg /dL.

29. Objective of exchange transfusion To stop haemolysis and Bilirubin production To correct Anemia and to improve congestive cardiac failure of the neonate To remove the the circulatory antibodies To remove sensitized RBC To eliminate the circulatory bilirubin. To stop hemolysis and bilirubin double production

30. Nature and amount of blood transfused Blood for exchange should be RH negative whole blood with the same blood ABO grouping to that of the baby otherwise group o. The blood should be collected relatively fresh The amount is about 160 ml/kg body weight of the baby.

31. Procedure of exchange transfusion The procedure is best to be carried out under a servo control radiant warmer. The route of transfusion should preferably be through the umbilical vein. A plastic catheter of 1 mm diameter is passed about 7 cm beyond the umbilicus so as place it in the inferior vena cava. In late transfusion femoral root through saphenous vein is the choice. Entire set should be Air tight and to be periodically flushed with heparinized saline to prevent clotting

32. Cont . Blood should be warmed to 37 degree Celsius 15 ml of fetal blood is withdrawn first followed by 10 ml to be pushed in return slowly . For every 100 ml of blood transfused, 1 Milli equivalents of sodium bicarbonate is given to to combat metabolic acidosis and 1 ml of 10% calcium gluconate to prevent tetany due to transfusion of citrated blood. To estimate the hemoglobin and Bilirubin concentration prior to and after the exchange transfusion. The procedures should be supervised by an expert team work.

33. Post transfusion care to baby The baby is placed under a radiant warmer. The umbilicus is to be inspected frequently for any evidence of bleeding. Serum bilirubin is to be estimated 4 hours after transfusion and to be repeated as required. Hypoglycemia is to be checked by blood glucose estimation post transfusion 4. hourly

34. Complication of exchange transfusion. Cardiac failure due to raised Venous pressure and overloading of the heart Air embolism Clotting and massive embolism Hyperkalemia Tetany Acidosis Sepsis Hypocalcaemia Hypoglycemia

35. Complication of hyperbilirubinemia Kernicterus Kernicterus is a pathological condition characterized by yellow staining of the brain by unconjugated bilirubin resulting in neuronal injury. The critical level of bilirubin causing Kernicterus in a term infant is more than 20 mg/dL. Clinically characterized by – Lethargy, hypotonia, poor feeding and loss of neonatal reflexes. Severe illness is manifested by respiratory distress , prostration, opisthotonus, nystagmus , hyperpyrexia , convulsions, enlarged liver and spleen.

36. Prevention and management Regular and periodic estimation of serum bilirubin level in susceptible babies. Exchange transfusion and phototherapy are used to effectively treat the condition.

37. Prevention of neonatal jaundice Promote and support breastfeeding Establish nursery protocols for identifying and evaluating hyperbilirubinemia. Measures bilirubin level in all neonate with jaundice in the first 24 hours Recognise that visual estimation of bilirubin level in accurate Interprete bilirubin level according to baby age in hours Risk assessment for all newborn babies.

38. Summary

39. Evaluation Define Icterus neonatorum How many types of neonatal jaundice. What is physiological jaundice
What is physiological jaundice What are the methods of treatment of jaundice What are the preventive methods of neonatal jaundice

40. Bibliography Bhaskar nima ” textbook of midwifery and obstetrical nursing” 3 rd edition , EMMESS publication page
no 598-603. 2. Jacob annamma , “ a comprehensive textbook of Midwifery and gynecological nursing, 4 th edition , Jaypee publication Ltd Page no 631-637. 3. Konar hiralal ,” DC Dutta’s textbook of obstetrics”,9th edition Jaypee publication, page no 446- ,449 4. www.slideshare.net